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Wisconsin Department of Safety and Professional Services _ �3 Page of <br /> Division of Industry Services <br /> SOIL EVALUATION REPORT <br /> In accordance with SPS 385,Wis. Adm. Code County <br /> Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must include, <br /> but not limited to:vertical and horizontal reference point(BM),direction and percent slope, Parcel.l D. `//._1S 7 <br /> scale or dimensions,north arrow,and location and distance to nearest road. ci7-G 3s-a` OY0000 <br /> Please print all information. R ed by D t <br /> Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). 5 .gym <br /> Property Owner _ Property Location ❑ <br /> A.a(. q- -e-I e' e Govt.Lot '/ '/< S 7 T N R I j' E (or) W <br /> --- <br /> Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# <br /> 63 rd 7e,-. � qv <br /> City State Zip Code Phone Number ❑City ❑Village ©Town Nearest Road 3009'! <br /> Jck F1 311"ty3 ) I 1 1 <br /> ❑ New Construction Use:®Residential/Number of bedrooms J Code derived design flow rate 3,60,GPD <br /> ® Replacement ElPub,l1"�or commercial-Describe: <br /> Parent material KleL C t 4, by,I Flood Plan elevation if applicable <br /> General comments and recommendations: ��,u jrt, . <br /> ❑Boring <br /> Boring# Pit Ground surface elev.9�'>ft. Depth to limiting factor >Yti in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2 <br /> In. Munsell Qu.Az.Cont.Color Gr.Sz.Sh. <br /> *Eff#1 *Eff#2 <br /> c-y 7s�i�Zs/� 15 imsb/L '7 1. 6 <br /> b» <br /> 3 Y- 8-f 7 3"'1 � s a d -71, t - 7 1, 6 <br /> Boring# ❑Boring . <br /> Pit Ground surface elev. Depth to limiting factor ���in. <br /> Soil Application Rate <br /> Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2 <br /> In. Munsell Qu.Az.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 <br /> O - �i 5 /l? --1/� i 1 /Mj 6 is . 7 A � <br /> *Effluent#1 =BOD,>30 5 220 m /L and TSS>30<-150 mg/L *Effluent#2=BOD,>30<_220 mg/L and TSS>30 5 150 mg/L <br /> CST Name(Please Print) Signature CST Number <br /> Address d 77C Z) /y+•-y 3-t Date Eva ation Conducted Telephone Number <br /> LV e 66i-r tv -S-;�rs S 7 G - d -1 7 7IS= Y6 , - e-1/f7 <br /> SBD-8330(R04/15) <br />